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General NPI Number Information
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NPI Number | 1730567207
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Entity Type | Organization
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Legal Business Name | JACQUES GOURGUECHON, LPC
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Dates
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Enumeration Date | 05/15/2015
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Last Update Date | 05/15/2015
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Provider Practice Location Address
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Address Line | 1454 W FARRAGUT AVE
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City | CHICAGO
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State | IL
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Zip | 60640-2104
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Country | US
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Telephone | 312-203-9211
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Fax |
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Provider Business Mailing Address
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Address Line | 1454 W FARRAGUT AVE
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City | CHICAGO
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State | IL
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Zip | 60640-2104
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Country | US
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Telephone | 312-203-9211
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Fax |
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Authorized Official
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Title or Position | PRINCIPAL
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Name | JACQUES A. GOURGUECHON
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Credential | LPC
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Telephone | 312-203-9211
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 178.010830
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License Number State | IL
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